Treatment Options by Stages:

Occult Stage

In the occult stage (TX, N0, M0), cancer cells are found in a sample of a patient's coughed-up sputum, but no cancer cells have yet been detected in the lung.

Treatment Options. Surgically removing the tumor (if one can be located) can allow doctors to identify the stage, and often results in a cure.

Stage 0 or Carcinoma in Situ

Stage 0 or carcinoma in situ (Tis, N0, M0) are noninvasive cancers. Only a few layers of cancer cells are detected within one local area. The cancer has not grown through to the top lining in the lung and can be surgically removed. There is a high risk for development of a second tumor, however.

Treatment Options:

• Surgery, often a limited procedure, where only part of a lobe is removed from the lung.
• In patients who cannot be treated surgically, consider photodynamic therapy, cryotherapy, or brachytherapy (discussed below).

Stage I

In stage I, the cancer has reached the higher layers of the lung but has not spread into the lymph nodes or beyond the lung.

General Treatment Options. The primary treatment is surgery, such as lobectomy (removal of a whole lobe), if possible. Patients with poor lung function should have partial lobectomy, if possible. Radiation treatments may be appropriate and beneficial for patients who cannot have surgery. It is not clear if early-stage lung cancer patients who have radiation or chemotherapy in addition to surgery have higher survival rates. The overall 5-year survival rates for early stage-cancer are in the range of 30 - 50%. Patients should consider clinical trials to prevent cancer from returning after the initial treatment. The risk for recurrence is highest in patients who continue to smoke.

• Stage IA (T1, N0, M0). Treatment options are:
  • Lobectomy or sometimes pneumonectomy (removal of one lung).
  • Wedge or segment removal, particularly in patients with poor lung function who cannot handle lobectomy.
  • Radiation in selected patients whose condition is inoperable (for example, frail patients) or whose cancer cannot be fully removed.
  • In general, chemotherapy is not done following surgery unless the tumor is not completely removed.
• Stage 1B (T2, N0, M0). Treatment options are:
  • Lobectomy or sometimes pneumonectomy; wedge or segment removal, particularly in patients with poor lung function.
  • Radiation in selected patients whose condition is inoperable (for example, frail patients) or where the tumor cannot be completely removed.
  • In general, chemotherapy is not done following surgery unless the tumor is not completely removed.

Stage II

In stage II the cancer cells have spread to nearby lymph nodes.

General Treatment Options. Surgery, usually removal of a lobe (lobectomy) or one lung (pneumonectomy), is the treatment of choice. Five-year survival rates associated with stage II surgery can vary.

If the tumor is completely removed, radiation therapy is usually not performed after surgery. Patients whose cancer is inoperable may consider radiation and chemotherapy treatments.

Patients who do well after surgical removal of the tumor often receive a platinum-based chemotherapy regimen.

In patients who can complete treatment, 5-year survival rates average 20 - 30%, with higher rates for stage IIA.

Stage III

In stage III, the cancer cells have spread beyond the lung to the chest wall, diaphragm, or further lymph nodes, such as those in the neck.

General Treatment Options. Generally, the treatment of choice for stage III tumors is radiation and sometimes surgery, chemotherapy, or combinations of all three.

Combination approaches may be significantly more effective than single treatments. One treatment approach starts with chemotherapy and radiation, given at the same time, followed by surgery. In one study, 5-year survival in stage III patients treated this way was nearly 50%.

• Stage IIIA (T1, N2, M0) or (T2, N2, M0) or (T3, N1, M0) or (T3, N2, M0).
  • Surgery, if the tumor and affected lymph nodes can be completely removed. Consider platinum-based chemotherapy or radiation therapy after surgery.
  • Radiation treatment plus platinum-based chemotherapy, given at the same time, is an option for those in otherwise good health. This regimen should be followed by surgery, if possible. This is generally not recommended outside of a clinical trial, however.
  • Consider clinical trials using advanced radiation techniques, including continuous hyperfractionated accelerated radiation, or 3-D conformal radiation (discussed below).
  • Consider other clinical trials, including those of various combination treatments, preventive radiation therapy to the brain, and new drugs.
• Stage IIIB (Any T, N3, M0) or (T4, Any N, M0). Some patients may consider surgery if the lymph nodes are not involved (T4, N0), and the tumor can be removed. Surgery is not an option for other patients with stage IIIB cancer.

Treatment Options.

• Radiation alone, usually for symptom control; it may improve survival in certain patients, such as those with lymph node involvement above the collar bone
• Chemotherapy alone
• Cisplatin-based chemotherapy given at the same time (concurrent) as radiation, sometimes followed by surgery, if possible
• Clinical trials using induction chemotherapy alone to shrink tumors, which may then be treated with surgery or radiation
• Clinical trials using advanced radiation techniques, including continuous hyperfractionated accelerated radiation, or 3-D conformal radiation
• Other clinical trials, including those of various combination treatments, preventive radiation therapy to the brain, and new drugs

Stage IV

In stage IV (any T, any N, M1), the cancer has spread (metastasized) to other parts of the body.

Treatment Options.

• Combination of two- or three-drug chemotherapies that include platinum-based drugs and newer drugs; the best candidates are patients in otherwise good health, who have a limited number of distant tumors. Chemotherapy is not recommended for patients who are too ill.
• Bevacizumab (Avastin) may be used for patients with non-squamous lung cancer, no spread to the brain, and who are not coughing up blood.
• External-beam radiation for symptom relief
• Paclitaxel, gemcitabine, or docetaxel are all additional drug options
• Other clinical trials
• If metastasized cancer involves only one or two areas in the brain, it may respond to surgery followed by radiation to the brain.

Recurring or Additional New Tumors

Recurring or new tumors occur (usually in the lung again) in half of treated patients. Research shows that a single tumor in the lung is more often a new tumor that, in many cases, may be operable.

Treatment Options.

• Radiation for symptom control
• Chemotherapy with or without bevacizumab (Avastin)
• If the cancer has spread to only one site in the brain, it may respond to surgery, followed by whole-brain radiation. Extended disease-free survival is possible. If the brain tumor is not operable, it is treated with radiation. Even if cancer returns in the brain (in 50% of cases), treating it again is possible in many patients, if the disease has not spread elsewhere in the body.
• Laser therapy or interstitial radiation for tumors inside the airways
• Stereotactic radiosurgery (in a few selected patients)